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					Preparing Our Communities To
 Help Our Returning Soldiers

                     Lanny Endicott, LCSW, D.Min.
                              lendicott@oru.edu
           http://drlannyendicott.com.tripod.com
                           Dexter Freeman, Ph.D.
                Dexter.Freeman@amedd.army.mil
           Some Information
                 Lanny Endicott

• 2,200,000 service members have experienced
  deployment to Iraq (OIF) and Afghanistan (OEF)
• 800,000 have experienced multiple deployments
• 43% of today’s fighting force is comprised of
  Reserve and Guard members
• 1% of the US population involved
• $4 trillion expended
• Approximately 35+% return afflicted with TBI
  and PTSD
• Those who deploy more than once have 300
  % increased probability for severe mental
  health outcomes
• At least 130,000 and as many as 250,000 U.S.
  veterans are homeless each night (over 7,000
  are veterans of Iraq or Afghanistan)
• Suicide is now the top killer of military
  veterans
Up to 31 percent of soldiers
returning from combat in Iraq
experience depression or post-
traumatic stress disorder that
affects their jobs, relationships, or
home life, according to a new study
by Army researchers.
81 percent of Veterans
suffering from depression and
PTSD engaged in at least one
violent act against their partner
in the past year.
Active-duty female personnel make up
roughly 14.5 percent -- or 207,308
members -- of the more than 1.4 million
Armed Forces, according to the
Department of Defense.

One in three military women has been
sexually assaulted, compared to one
in six civilian women, according to
DoD
Military and Domestic Violence:
          Risk Factors

• High percentage of military
  personnel have prior histories of
  family violence.

• Among Navy recruits, 54% of women
  and 40% of men witnessed parental
  violence prior to enlistment
            Risk Factors
• Military population is concentrated in
  the ages of highest risk for
  interpersonal violence (ages 20-40)

• Constant mobility and geographic
  separation isolates victims by cutting
  them off from family and other support
  systems
  Military and Domestic Violence
            Risk Factors
• Higher than average unemployment rates
  for military spouses, leaving them
  economically dependent on service
  members
• Deployments and reunifications create
  unique stresses on military families
“Our military does an exceptional job of preparing
soldiers, Marines, sailors and airmen for the fight –
boot camp makes warriors of recruits – but we do
little to ‘de-boot,’ to support that warrior and his or
her family as he or she comes out of the extraordinary
experience of having served in combat. A prosthetic
leg, some physical therapy and a bottle of meds do
not equal a homecoming plan.”


Nancy Berglass. America’s Duty: The Imperative of a New Approach to Warrior
and Veteran Care. November 2010. Center for a New American Security.
          Workshop Objectives
• Articulate how military culture can both help or
  hinder community re-integration
• Describe 2 evidence-based treatment modalities for
  treating service members with PTSD
• Introduce “traumatic brain injury”
• Address the concept of “soul or moral injury”
  affecting our service members and discuss ways
  social workers of faith can address the issue
    3,300 Members of the
Oklahoma National Guard have
     returned home from
     Afghanistan/Kuwait
            A New Paradigm
• Despite their best intentions DOD and VA are
  overwhelmed
• Less that 50% of veterans access services of
  the VA - particularly “mental health’
• Private sector partners (non-profits and for-
  profits) can provide important services – but
  need assistance with funding and training to
  address the needs of veterans
• A key is that personalized care for our
  veteran warriors includes the VA and
  community partners working together
            Community Partners
Engage coordinated and informed community planning efforts
                  VA + Community
• Community-based social service providers
• Educational institutions (universities, colleges,
  tech schools)
• Faith communities (churches, synagogues, etc.)
• Court systems (Veterans Court)
• Employers
• Veterans Administration
• Military support organizations (Wounded
  Warriors, Folds of Honor, Blueprint, Give an
  Hour)
               Veterans Initiative
         Community Service Council (Tulsa)

• Bring agencies/organizations together to
  discuss what they do
• Discover gaps/needs in services to veterans
  – Preparation of therapists to accommodate
    veteran clientele:
     • military culture
     • evidenced based treatment for PTSD
  – Develop a “go-to-provider” in each agency: one
    trained who functions as trainer for others
      Wounded Warriors’ Grant
• Community Service Council (Veterans
  Initiative)
• Three parts:
  – Military Culture
  – Cognitive Processing Therapy (Duke and TU)
  – Create a “learning community” for application
    and feedback of CPT
• Goal: train 60 therapists
     ID Veterans and Families

• Identification of veterans and their families at
  social services, doctors offices, employers,
  educational institutions, etc.
   Add a question on veteran status in intake forms
           Veterans Courts
 Promote establishment of Veterans Courts
 Tulsa has Veterans Courts on both County and
  City level
 Modeled after the “drug court”
 2-year program: treatment, case management,
  mentors
Preparing Educational Institutions
 • Educational institutions should have:
    Go-to person to work with veterans
    Veteran organization
    Veterans Lounge (private meeting place)
    Training of faculty and staff for working with veterans
    Referral network for assisting veterans and their
      families
    See SVA Toolkit: www.vetfriendlytoolkit.org
     University of Denver Study
• Of 800,000 veterans who attended college
• 88% dropped out after the first year
• 3% graduated from college
              Coffee Bunker
• Tulsa is a large community without a military
  instillation nearby
• Coffee Bunker is an evening drop-in center for
  veterans of all services
• Volunteers are trained in QPR
• Recent grants from Wounded Warriors and
  United Way (Venture Grant) will help expand
  program to its own site
                  Summary

In general, prepare and educate the community
for veteran reintegration
 •   Remember the 1%
 •   $4 trillion of borrowed money
 •   Lack of sacrifice from the community in general
 •   Old news becomes less newsworthy
  A Matter of National Defense
“The willingness with which our young
people are likely to serve in any war, no
matter how justified, shall be directly
proportional to how they perceive the
Veterans of earlier wars were treated and
appreciated by their nation.”

President George Washington
WHEN YOU THINK OF THE MILITARY
(UNIQUE FACETS)
•   Frequent separations
•   Regular household relocations
•   Mission comes first
•   Early retirements
•   Loss
•   Detachment
•   System security
•   Rank focused
THE DEPLOYMENT CYCLE
(EMOTIONAL FACTORS)
• Predeployment – “Gearing up”
  • Anticipation, detachment, sadness, restless
• Deployment – “Boots on the ground”
  • Emotional disorganization, sleep disturbance
  • New patterns, psychological presence
• Postdeployment (Redeployment)
  • Relief, boundary ambiguity
  • New normal, prepping to gear up
COPING WITH DEPLOYMENT
(AWAITING SPOUSE’S CONCERNS)
•   Safety of Deployer (49%)
•   Loneliness (47%)
•   Anxiety or depression (36%)
•   Difficulty sleeping (36%)
•   Sole parent concerns (32%)
•   Inaccurate information (31%)
•   Household duties/repairs (28%
•   Job/education demands (26%)




                   DATA FROM 2008 SURVEY OF ACTIVE DUTY SPOUSES,
                            DEFENSE MANPOWER DATA CENTER (2009)
          For training in military culture
Military Culture: “Paint a Moving Train” (Kudlar)
   http://www.mirecc.va.gov/visn6/paint-moving-train.asp

For introduction to treatment of PTSD (Cognitive Processing
  Therapy):
  http://www.ptsd.va.gov/professional/ptsd101/ptsd-101.asp

  http://cpt.musc.edu
“Psychological First Aid”
  http://www.ptsd.va.gov/professional/manuals/psych-first-aid.asp

  What we know about Army Families: 2007 update
  http://www.army.mil/cfsc/research.htm
                    PTSD
• Think of PTSD as inability to recover from a
  traumatic event
• In normal recovery, intrusions and emotions
  decrease over time and no longer trigger
  each other
• In those not recovering, strong negative
  emotion leads to escape and avoidance
            Symptoms of PTSD
Three Categories:
1. “Reliving” the event:
  •   Flashbacks
  •   repeated upsetting memories of the event
  •   repeated nightmares
  •   strong uncomfortable reactions to situations
      that remind one of the event
2. “Avoidance” or emotional numbing or feeling one
   doesn’t care about anything
  •   Feeling detached
  •   Being unable to remember important aspects of
      event
  •   Having lack of interest in normal activities
  •   Avoiding reminders of event: places, people,
      thoughts
  •   Showing less of one’s moods
  •   Feeling like one has no future
3. Arousal
  •    Difficulty concentrating
  •    Startling easily
  •    Exaggerated response to things that startle
  •    Feeling more aware (hypervigilance)
  •    Feeling irritable or having outbursts of anger
  •    Having trouble falling or staying asleep
  •    Feeling guilt about the events (“survivor guilt)
  •    Symptoms typical of anxiety, stress, tension:
      o Agitation or excitability, dizziness, fainting,
          feeling heart beat in one’s chest, headache
           PTSD Treatment
VA recognizes two therapies with best
evidence:
– Cognitive Processing Therapy (CPT)
– Prolong Exposure Therapy (PET)
VA website for Cognitive Processing Therapy
    http://www.ptsd.va.gov/public/pages/cognitive_process
        ing_therapy.asp
VA website promoting Mobile App: PTSD Coach
    http://www.ptsd.va.gov/public/pages/PTSDCoach.asp


Mobile App: PE Coach
       Traumatic Brain Injury (TBI)
Symptoms of Mild TBI
•   Brief loss of consciousness (seconds to minutes)
•   Headache
•   Vomiting
•   Nausea
•   Lack of motor coordination
•   Dizziness
•   Difficulty balancing
•   Lightheadedness
•   Blurred vision or tired eyes
•   Ringing in the ears
•   Bad taste in the mouth
•   Fatigue or lethargy
•   Changes in sleep patterns
•   Behavioral or mood changes
•   Confusion
•   Trouble with memory, concentration, attention, or
    thinking
               Moral Injury
• Is a suspected contributor to soldier suicide
• Is not PTSD: an injury of trauma leading to
  suppression of fear and lack of integration of
  feelings with coherent memory – leading to
  symptoms including flashbacks, nightmares,
  dissociative episodes and hyper-vigilance
• Moral injury is a negative self-judgment
  based on having violated core moral beliefs
  and values or feeling betrayed by one in
  authority
• It includes loss or destruction of moral
  identity and loss of meaning
• Its symptoms include shame, survivor guilt,
  depression, despair, addiction, distrust,
  anger, a need to make amends and the loss of
  desire to live
     A Consequence of Training
• “Mission first” training – can contribute to
  resiliency in soldier’s mission (including
  survival) while ignoring empathy for others
  and deep moral values
• Soldiers taught to see events in a neutral
  light, not labeling them as good or bad, and
  to focus on those things that are positive
• A soldier could experience the
  incomprehensible while on mission: killing a
  family, including women and children, after
  kicking down the door of suspected
  insurgent; losing a close friend; or torturing
  detainees?
• Will the soldier see as neutral or positive?
              Person of faith
• Many soldiers seek the help of clergy:
  – To avoid a negative psychological record
  – To seek help with religious meaning, moral
    issues, and matters of conscience
• Social workers of faith can also provide caring
  and empathetic help through careful listening
  and understanding as soldiers may seek
  community professionals to avoid mental
  health labeling
                Treatment
• Moral injury is not a clinical condition that
  can be medicated or cured by psychology
• Requires the reconstruction of a moral
  identity and meaning in life with the support
  of a caring, nonjudgmental community
  (chaplain, pastor, therapist, social worker)
  that can provide a way for the veteran to
  learn to forgive
             PTSD Treatment
Cognitive Processing Therapy
• Address event(s) – thinking – feelings
  connection
• Writing about detailed trauma event(s) &
  reading them to the therapist
• Utilizing worksheet assignments
Prolonged Exposure
• Teach relaxation
• Expose person to discussing/experiencing
  traumatic event (invivo – imaginal)
                Moral Injury
• Two types of violations: co-mission or
  omission
• Violation of moral, cultural, religious and/or
  other deeply held beliefs
• Military training emphasizes mission with
  suppression of individual beliefs
• Moral Injury does not come from a specific
  traumatic event
      Treatment of Moral Injury
• Shame: the consequence
• Forgiveness, repentance: the treatment via help
  from community therapists, clergy, chaplains, or
  trusted moral authority
• Honor: community events, ceremonies
  celebrating and honoring returning soldiers


   “Honor is the antidote of shame”
                     Grief
• The soldier may be experiencing “grief” from
  loss (i.e., death of colleague, separation from
  unit & mission, leaving of spouse)
• The treatment is an application of “grief
  therapy”: talk through the loss while
  recognizing that people process grief
  differently
       Resources for Moral Injury


http://www.ptsd.va.gov/professional/pages/moral_injury_at_
   war.asp

http://www.commondreams.org/view/2012/06/29-8
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